Monday, May 13, 2013

A Gut Feeling: Somewhere Between Celiac Disease and Wheat Allergy

By Steven Cole, DODallas Allergist and Immunologist

It happens every day in medical clinics across the country, and the odds are that it will
happen again today in Dallas. A patient diligently researches a slew of websites
detailing symptoms related to her complaints about celiac disease, wheat allergy or
gluten sensitivity. She asks her doctor for confirmation only to find the doctor rolling his
eyes after the patient has shared her conclusions.

Why do these doctors think they know more than their patient who spent hours in online
research? The doctor is merely playing the odds. He sees dozens of patients each
week with similar complaints that turn out to be something else. Only about 1% of the
population has celiac disease, and less than 2% has wheat allergy. About 20-25% of
adults believe they have a food allergy or intolerance to some food; however, when
researchers performed food challenges under controlled conditions, the true number
dropped to only about 4%. Many of the symptoms of celiac disease and food allergy
overlap with irritable bowel syndrome and depression, which are far more common.

If you Google “gluten-free Dallas,” 957 results return. The website Urbanspoon lists 489
restaurants in DFW as “gluten-friendly.” So if celiac disease only affects 1% of the
population, and wheat allergy is about the same percentage, why all the fuss over
gluten free? The answer lies somewhere in the murky waters of the poorly defined and
not well-understood term gluten sensitivity. A recent review of celiac disease in The New
England Journal of Medicine describes gluten sensitivity as presenting with both
gastrointestinal symptoms and some outside the GI tract, but that the GI symptoms are
indistinguishable from celiac disease and wheat allergy. Most people understand the
term wheat allergy, and more people are now familiar with the term celiac disease;
however, the term gluten sensitivity is still difficult to understand for many doctors
(especially those with a proclivity to find interest on the ceiling during their interview) let
alone the general population.

Perhaps the question of gluten sensitivity is as much a geographic problem as a gut
problem. When one maps the restaurants that specifically cater to the gluten sensitive
crowd, the results are quite interesting. Yelp, a website that posts user reviews for
restaurants, lists 20 gluten-free restaurants in North Dallas, but only 2 in South Dallas.
Highland Park has 11 listings, while Oak Cliff has none. Are there genetic or racial
differences among these neighborhoods? It is true that celiac disease is more common
in Caucasians and is much more common in people with certain genetic factors.The
same genetic association has not been found in gluten sensitivity, however.

Some have pointed out that the majority of patients with gluten sensitivity seem to be
females with depression or anxiety. Perhaps the women in more affluent neighborhoods
have the luxury of time to worry more about health problems than the women from the
financially disadvantaged neighborhoods who are struggling to make ends meet. I
recently purchased a cake mix for $1.49 at my local grocery store, and the gluten-free
version of the same cake mix was $4.59. It then occurred to me that it’s more than just
time that is required to keep up with this diet--it’s money. Doctors that continue to roll
their eyes at patients will soon find out that they can’t afford to pay for all the gluten-free
fare purchased by their own spouse or children.

I recently ordered a sandwich from the deli at Whole Foods. I was interested to hear
from the guy behind the counter that all of the ingredients were organic, and that even
though the sandwich was not necessarily low in calories, the calories were “honest
calories.” In the spirit of honorable foods, I decided to skip my usual diet soft drink in
favor of a more moral green tea. I even decided to eat my meal outside under the sun
as opposed to the unprincipled fluorescent glow of my office. Perhaps it was being away
from my hectic workplace to enjoy an unseasonably warm day, or perhaps it was all that
“honest” pesto that had gone to my head, but either way I felt great.

The mind-body connection is difficult to ignore, and may some day play a much larger
role in our understanding of these “not quite food allergic” patients. There is currently no
reliable way to distinguish between groups of patients with symptoms related to gluten
consumption versus those with symptoms completely unrelated to gluten. Perhaps
some day we will develop a test that will once and for all separate the wheat from the
chaff.

I've also struggled with identifying these patients better/more specifically. Few have positive gliadin or tTG antibodies. I've tried the ALCAT test which claims to also identify hypersensitivity reactions within white blood cells by remain skeptical as to the clinical utility (results often have a lot of foods "in the red"). Any experience or opinions with this test?

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